THYROID/PARATHYROID

I. Introduction/General Information A. Thyroid 1. Endocrine gland a. Lobes are cone shaped b. Apex extends to oblique line of thyroid cartilage 2. Highly vascular

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3. Anterior & lateral to larynx, trachea 4. Lobes connected by an isthmus 5. Pyramidal lobe may be present 6. Normally not palpable

The Thyroid Gland

Located in the anterior region of the neck This gland has an accessory (pyramidal) lobe

Thyroid Gland, Anterior and Posterior Views

Thyroid Gland: anterior view (left); and posterior view (right)

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8. Isthmus crosses tracheal cartilages 2-4

9. Base located ~4-5th tracheal cartilage 10. Thyroxin function: regulates basic metabolism in all cells

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B.

Parathyroid glands

1. Usually four two on each side (2-8 is normal) 2. Lie on the posterior surface of thyroid 3. May be embedded within thyroid gland 4. Regulate calcium/phosphate levels 5. Required for life

Parathyroid Glands (Post. view of thyroid)

Parathyroid Glands are located on the posterior aspect of the thyroid; sometimes the tissue is embedded within thyroid tissue.

II. Detailed Anatomy A. Thyroid 1. Largest endocrine gland in adult 2. Normally extends from ~ C-5 through ~ T-1 3. Highly vascular

4. Weights ~20 - 30 grams

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5. Pyramidal lobe a. present in ~ 33% of population. b. Extends upward from isthmus c. anterior to thyroid cartilage

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d. Embryologic remnant of thyroglossal duct

e. formerly connected cecum of tongue to thyroid diverticulum

f. Site of developing gland

Pyramidal Lobe of the Thyroid Gland

Pyramidal Lobe

Thyroid Gland, Anterior View

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c. Lobes:
1. Attached to cricoid cartilage by ligaments 2. Medial surface adapted to larynx and trachea

Thyroid, Detailed Anatomy, cont

3. Lobes related posteriorly to the esophagus

4. Posterolateral surface

a. related to carotid sheath

b. overlaps carotid artery

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d. Isthmus
1. 1.25 cm x 1.25 cm 2. Crosses @ tracheal rings ~2-4 3. Occasionally absent

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6. Highly vascular gland supplied by four large arteries a. R & L inferior thyroid artery b. R & L superior thyroid artery

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7. Drained by R & L superior, middle and inferior thyroid veins a. Veins arise from plexus b. on anterior surface of gland c. Extend over anterior surface of trachea
Inferior Thyroid Vein

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d. Lymph vessels
1. In interlobular connective tissue between lobes 2. Connect with network in wall of gland 3. terminate in thoracic and right lymphatic ducts

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8. Muscular landmarks
a. Sternocleidomastoid muscles lie laterally b. Longus colli (prevertebral) muscles lie posteriorly c. Strap muscles lie anteriorly

Strap Muscles

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9. Autonomic innervation via a. Cervical portion of sympathetic trunk b. Parasympathetic fibers arise from Vagus X

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9.

Treatment considerations
a. Superior thyroid artery is accompanied by superior laryngeal nerve b. Inferior thyroid artery is accompanied by recurrent laryngeal nerve

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c. Damaging nerves results in partial or total paralysis of larynx d. Bordered by neurovascular structures contained in carotid sheath

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11. Pretracheal fascia:

a. surrounds thyroid b. Extends from hyoid bone to fibrous pericardium c. Encloses trachea, larynx, pharynx, thyroid d. Parathyroids and venous plexus lie between layers

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d. Fascia more dense anteriorly

1. Thyroid enlargement often occurs posteriorly 2. May compress trachea, esophagus 3. 1st symptom may be hoarseness, difficulty swallowing

Parathyroid Gland, Detailed Anatomy

B. Parathyroid glands 1. Yellow-brown 2. ovoid or lentiform structures 3. weigh ~ 50 mg each 4. Measure 3-10 mm x 2-6 mm x 1-4 mm

Parathyroid Glands, cont.

5. Lie between posteromedial thyroid lobes and carotid sheath

6. Close proximity to: a. Tracheoesophageal groove b. longus colli muscles

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7. Position of superior glands is more predictable

8. Aberrant glands may lie between trachea and thyroid

9. Blood, lymphatic and nerve supply: same as for thyroid

III. Thyroid/Parathyroid Diseases

A.
B.

Ultrasound useful in differentiating cystic from complex or solid masses Thyroid Cysts 1. Typical cystic appearance 2. Colloid cysts 3. Thyroglossal duct cysts

Pathology, cont

3. Branchial cleft cysts a. More specific than pattern for other neoplasms

b. Are usually more cephalic

4. Only 20% of thyroid masses are simple cysts

Pathology, cont

C. Structures of Carotid Sheath 1. Jugular vein, carotid artery 2. Delineate lateral aspect of thyroid 3. Jugular vein lateral to carotid artery a. vein has greater diameter b. Is distensible on valsalva maneuver

Transverse Section of Thyroid Gland

Trachea Sternocleidomastoid Muscle Internal Jugular Vein Common Carotid Artery Thyroid Gland, Left Lobe

Brachial Plexus Esophagus

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D. Thyroid is more homogeneous and echogenic than surrounding muscle

1. Sternocleidomastoid (lateral) 2. Longus colli (posterior)

E. US is less helpful w/ complex masses or diffuse parenchymal disorders

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F. Parathyroids are difficult to see 1. Size and location are variable 2. Usually: a. moderately echogenic
b. c. d. e. well-circumscribed capsule around anterior to longus colli medial to common carotid a.

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3. Longus Colli (prevertebral) Muscles a. Attachments: 1. O = cervical vertebrae 2. I = cervical vertebrae b. Action: twists, bends neck c. Lie posterior

IV. Thyroid Diseases

A. Metastasis from thyroid cancer

1. May invade local structures a. trachea b. esophagus c. carotid artery d. jugular vein

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2. Innervation may be involved a. Voice, speech changes

b. Horners Syndrome of eye 1. droopy eye 2. dryness 3. small pupil

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B. Cystic Masses 1. Colloid cyst:

a. Contains thyroglobulin
b. May have hemorrhagic center

c. May be aspirated

Thyroid Follicles showing Colloid

Thyroid Follicles with colloid containing Thyroid hormones

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2. Branchial cleft cyst

a. Usually more cephalic

b. Non-closure of a branchial cleft c. lie laterally

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3. Thyroglossal Duct Cyst a. Lies @ midline b. Represents non-closure of thryoglossal duct c. Congenital anomaly:
1. retention of tract 2. between thyroid and foramen cecum

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d. Usually surrounded by hyoid bone e. More frequently diagnosed in pediatric age groups

f. may be asymptomatic

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g. Incidence in patients undergoing thyroid surgery:

1. 4% have this cyst

2. 28% of those with the cyst are > 50 years old

h. Symptoms: painless swelling at midline of neck

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i. Treatment:
1. excision of cyst & central hyoid bone
2. < 1% accompanied by cancer

j.

Account for ~ 70% of congenital cysts of neck

k. may appear at any location along duct

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C. Complex/Solid Masses (Neoplasm)

1. Adenoma
a. Well-encapsulated

b. Usually solitary
c. Homogeneous

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c. May be complex, with

1. sonolucent halo 2. echogenic center

d. 50% of thyroid cancers are papillary adenocarcinomas

2. Complex solid masses show increased malignancy

Adenoma of the Thyroid Gland

Note atrophy of the left lobe with the tumor protruding from it Right lobe may hypertrohy to compensate for loss of function in L. lobe

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3. Goiter

a. Enlargement of thyroid gland

b. due to insufficient iodine

c. Gland appears nodular with irregular outline

d. Grossly enlarged

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e. Nodules have variable echogenicity

f. Treatable with iodine in diet

g. More common inland, and before iodized salt

Types of Goiters

Simple Goiter (L) and Nodular (Toxic) Goiter (R)

D. Parathyroid Diseases 1. Benign adenoma a. Relatively common b. usually results in hyperparathyroidism 2. Cancers are rare 3. Surgical excision gives > 90% cure rate

Parathyroid Diseases

Pathogenesis of Hyperparathyroidism

PTH increases blood calcium levels Acts on bone, kidneys, small intestines

Hyperparathyroidism

Long-term Effects on the Skeletal System